CMC (Cardiac Medicine Certification) Certification
recognizing advanced cardiac nursing knowledge,
cardiovascular disease management, patient
monitoring, and therapeutic interventions.
1. A 58-year-old male presents to the ED with substernal chest pain radiating
to the jaw, diaphoresis, and nausea. ECG shows ST-segment elevation of 3
mm in leads V2-V4. What is the priority intervention?
• A) Administer sublingual nitroglycerin
• B) Obtain cardiac enzymes
• C) Emergent percutaneous coronary intervention (PCI) or fibrinolytic
therapy
• D) Start a heparin infusion
Answer: C
Rationale: ST-elevation myocardial infarction (STEMI) requires immediate
reperfusion. Emergent PCI is preferred if door-to-balloon time <90 minutes.
Fibrinolytics if PCI not available within 120 minutes. Do not delay for enzyme
results.
2. A 62-year-old with non-ST-elevation myocardial infarction (NSTEMI) has
ongoing chest pain at rest. Troponin is elevated. The most appropriate initial
medical therapy includes:
• A) Aspirin, beta-blocker, nitroglycerin, and heparin (or fondaparinux)
• B) Fibrinolytic therapy
• C) Only morphine and oxygen
• D) Immediate PCI without medical therapy
Answer: A
Rationale: NSTEMI management includes antiplatelet (aspirin, P2Y12 inhibitor),
,anticoagulation (heparin/fondaparinux), anti-ischemic (beta-blocker, nitroglycerin),
and risk stratification for early invasive strategy. Fibrinolytics are not indicated for
NSTEMI.
3. A 55-year-old with inferior STEMI develops hypotension, bradycardia (HR
45), and JVD. The most likely diagnosis is:
• A) Cardiogenic shock
• B) Right ventricular infarction
• C) Pericarditis
• D) Pulmonary embolism
Answer: B
Rationale: Right ventricular infarction occurs in up to 40% of inferior STEMI.
Hypotension, bradycardia, and JVD without pulmonary congestion suggest RV
involvement. Avoid nitroglycerin (preload dependent). Volume resuscitation is
first-line.
4. A patient with STEMI undergoes successful PCI to the left anterior
descending artery. Post-procedure, the patient develops a new harsh
holosystolic murmur at the apex radiating to the axilla, hypotension, and
pulmonary edema. The most likely complication is:
• A) Ventricular septal rupture
• B) Papillary muscle rupture with acute mitral regurgitation
• C) Left ventricular free wall rupture
• D) Pseudohypertrophy
Answer: B
Rationale: Acute mitral regurgitation from papillary muscle rupture (usually
posteromedial due to single blood supply) occurs 2-7 days post-STEMI.
Holosystolic murmur, hypotension, pulmonary edema. Surgical emergency.
,5. A 70-year-old with an anterior STEMI on day 3 develops sudden onset of
hypotension, electromechanical dissociation (PEA), and JVD. Pulsus
paradoxus is present. The most likely diagnosis is:
• A) Massive pulmonary embolism
• B) Cardiac tamponade from left ventricular free wall rupture
• C) Severe mitral regurgitation
• D) Ventricular septal rupture
Answer: B
Rationale: Left ventricular free wall rupture presents with sudden hemodynamic
collapse, PEA, and tamponade (pulsus paradoxus, JVD, muffled heart sounds). It is
often fatal but can be treated with emergency pericardiocentesis and surgical
repair.
6. A 50-year-old with NSTEMI is started on aspirin, clopidogrel, and heparin.
The patient develops sudden slurred speech and right-sided weakness. CT
head is normal. The most likely mechanism is:
• A) Hemorrhagic stroke due to antiplatelets
• B) Ischemic stroke from left ventricular thrombus
• C) Heparin-induced thrombocytopenia with thrombosis
• D) Air embolus
Answer: C
Rationale: Heparin-induced thrombocytopenia (HIT) with thrombosis can cause
stroke within 5-14 days of heparin exposure. Platelet count drops >50%.
Diagnosis: anti-PF4 antibodies. Stop heparin, start direct thrombin inhibitor
(argatroban, bivalirudin). CT negative for bleed suggests ischemic stroke.
7. A patient with inferior STEMI develops second-degree Mobitz II AV block.
Which intervention is indicated?
• A) Atropine 0.5 mg IV
• B) Observation; Mobitz II often resolves spontaneously in inferior MI
, • C) Immediate transcutaneous pacing
• D) Isoproterenol infusion
Answer: C
Rationale: Mobitz II AV block is a high-grade heart block, often unpredictable
and may progress to complete heart block with asystole. It is more common in
anterior MI; in inferior MI, heart block is often Mobitz I (Wenckebach) and
transient. However, Mobitz II requires pacing.
8. A 45-year-old with STEMI is given fibrinolytic therapy (tPA). One hour
later, the patient develops sudden severe headache, vomiting, and left-sided
weakness. The priority action is:
• A) Administer aspirin
• B) Stop tPA and obtain stat non-contrast CT head
• C) Give platelets
• D) Administer protamine sulfate
Answer: B
Rationale: Sudden neurologic deficit after fibrinolysis suggests intracranial
hemorrhage. Immediately stop tPA, give cryoprecipitate (fibrinogen) and
platelets, and obtain emergent CT head. Do not delay imaging.
9. A 60-year-old with STEMI has a door-to-balloon time of 75 minutes. The
patient is on dual antiplatelet therapy (aspirin + ticagrelor). After PCI, the
nurse notes a large groin hematoma and a drop in hemoglobin from 13 to 8
g/dL. The most appropriate intervention is:
• A) Apply manual pressure above the femoral puncture site
• B) Administer protamine sulfate
• C) Transfuse platelets
• D) Prepare for surgical vascular repair
Answer: A
Rationale: Retroperitoneal bleeding or large groin hematoma after arterial puncture
recognizing advanced cardiac nursing knowledge,
cardiovascular disease management, patient
monitoring, and therapeutic interventions.
1. A 58-year-old male presents to the ED with substernal chest pain radiating
to the jaw, diaphoresis, and nausea. ECG shows ST-segment elevation of 3
mm in leads V2-V4. What is the priority intervention?
• A) Administer sublingual nitroglycerin
• B) Obtain cardiac enzymes
• C) Emergent percutaneous coronary intervention (PCI) or fibrinolytic
therapy
• D) Start a heparin infusion
Answer: C
Rationale: ST-elevation myocardial infarction (STEMI) requires immediate
reperfusion. Emergent PCI is preferred if door-to-balloon time <90 minutes.
Fibrinolytics if PCI not available within 120 minutes. Do not delay for enzyme
results.
2. A 62-year-old with non-ST-elevation myocardial infarction (NSTEMI) has
ongoing chest pain at rest. Troponin is elevated. The most appropriate initial
medical therapy includes:
• A) Aspirin, beta-blocker, nitroglycerin, and heparin (or fondaparinux)
• B) Fibrinolytic therapy
• C) Only morphine and oxygen
• D) Immediate PCI without medical therapy
Answer: A
Rationale: NSTEMI management includes antiplatelet (aspirin, P2Y12 inhibitor),
,anticoagulation (heparin/fondaparinux), anti-ischemic (beta-blocker, nitroglycerin),
and risk stratification for early invasive strategy. Fibrinolytics are not indicated for
NSTEMI.
3. A 55-year-old with inferior STEMI develops hypotension, bradycardia (HR
45), and JVD. The most likely diagnosis is:
• A) Cardiogenic shock
• B) Right ventricular infarction
• C) Pericarditis
• D) Pulmonary embolism
Answer: B
Rationale: Right ventricular infarction occurs in up to 40% of inferior STEMI.
Hypotension, bradycardia, and JVD without pulmonary congestion suggest RV
involvement. Avoid nitroglycerin (preload dependent). Volume resuscitation is
first-line.
4. A patient with STEMI undergoes successful PCI to the left anterior
descending artery. Post-procedure, the patient develops a new harsh
holosystolic murmur at the apex radiating to the axilla, hypotension, and
pulmonary edema. The most likely complication is:
• A) Ventricular septal rupture
• B) Papillary muscle rupture with acute mitral regurgitation
• C) Left ventricular free wall rupture
• D) Pseudohypertrophy
Answer: B
Rationale: Acute mitral regurgitation from papillary muscle rupture (usually
posteromedial due to single blood supply) occurs 2-7 days post-STEMI.
Holosystolic murmur, hypotension, pulmonary edema. Surgical emergency.
,5. A 70-year-old with an anterior STEMI on day 3 develops sudden onset of
hypotension, electromechanical dissociation (PEA), and JVD. Pulsus
paradoxus is present. The most likely diagnosis is:
• A) Massive pulmonary embolism
• B) Cardiac tamponade from left ventricular free wall rupture
• C) Severe mitral regurgitation
• D) Ventricular septal rupture
Answer: B
Rationale: Left ventricular free wall rupture presents with sudden hemodynamic
collapse, PEA, and tamponade (pulsus paradoxus, JVD, muffled heart sounds). It is
often fatal but can be treated with emergency pericardiocentesis and surgical
repair.
6. A 50-year-old with NSTEMI is started on aspirin, clopidogrel, and heparin.
The patient develops sudden slurred speech and right-sided weakness. CT
head is normal. The most likely mechanism is:
• A) Hemorrhagic stroke due to antiplatelets
• B) Ischemic stroke from left ventricular thrombus
• C) Heparin-induced thrombocytopenia with thrombosis
• D) Air embolus
Answer: C
Rationale: Heparin-induced thrombocytopenia (HIT) with thrombosis can cause
stroke within 5-14 days of heparin exposure. Platelet count drops >50%.
Diagnosis: anti-PF4 antibodies. Stop heparin, start direct thrombin inhibitor
(argatroban, bivalirudin). CT negative for bleed suggests ischemic stroke.
7. A patient with inferior STEMI develops second-degree Mobitz II AV block.
Which intervention is indicated?
• A) Atropine 0.5 mg IV
• B) Observation; Mobitz II often resolves spontaneously in inferior MI
, • C) Immediate transcutaneous pacing
• D) Isoproterenol infusion
Answer: C
Rationale: Mobitz II AV block is a high-grade heart block, often unpredictable
and may progress to complete heart block with asystole. It is more common in
anterior MI; in inferior MI, heart block is often Mobitz I (Wenckebach) and
transient. However, Mobitz II requires pacing.
8. A 45-year-old with STEMI is given fibrinolytic therapy (tPA). One hour
later, the patient develops sudden severe headache, vomiting, and left-sided
weakness. The priority action is:
• A) Administer aspirin
• B) Stop tPA and obtain stat non-contrast CT head
• C) Give platelets
• D) Administer protamine sulfate
Answer: B
Rationale: Sudden neurologic deficit after fibrinolysis suggests intracranial
hemorrhage. Immediately stop tPA, give cryoprecipitate (fibrinogen) and
platelets, and obtain emergent CT head. Do not delay imaging.
9. A 60-year-old with STEMI has a door-to-balloon time of 75 minutes. The
patient is on dual antiplatelet therapy (aspirin + ticagrelor). After PCI, the
nurse notes a large groin hematoma and a drop in hemoglobin from 13 to 8
g/dL. The most appropriate intervention is:
• A) Apply manual pressure above the femoral puncture site
• B) Administer protamine sulfate
• C) Transfuse platelets
• D) Prepare for surgical vascular repair
Answer: A
Rationale: Retroperitoneal bleeding or large groin hematoma after arterial puncture
